HSS Journal

, Volume 7, Issue 2, pp 108–114

Thermal Shrinkage for Shoulder Instability

  • Alison P. Toth
  • Russell F. Warren
  • Frank A. Petrigliano
  • David A. Doward
  • Frank A. Cordasco
  • David W. Altchek
  • Stephen J. O’Brien
Original Article

Abstract

Thermal capsular shrinkage was popular for the treatment of shoulder instability, despite a paucity of outcomes data in the literature defining the indications for this procedure or supporting its long-term efficacy. The purpose of this study was to perform a clinical evaluation of radiofrequency thermal capsular shrinkage for the treatment of shoulder instability, with a minimum 2-year follow-up. From 1999 to 2001, 101 consecutive patients with mild to moderate shoulder instability underwent shoulder stabilization surgery with thermal capsular shrinkage using a monopolar radiofrequency device. Follow-up included a subjective outcome questionnaire, discussion of pain, instability, and activity level. Mean follow-up was 3.3 years (range 2.0–4.7 years). The thermal capsular shrinkage procedure failed due to instability and/or pain in 31% of shoulders at a mean time of 39 months. In patients with unidirectional anterior instability and those with concomitant labral repair, the procedure proved effective. Patients with multidirectional instability had moderate success. In contrast, four of five patients with isolated posterior instability failed. Thermal capsular shrinkage has been advocated for the treatment of shoulder instability, particularly mild to moderate capsular laxity. The ease of the procedure makes it attractive. However, our retrospective review revealed an overall failure rate of 31% in 80 patients with 2-year minimum follow-up. This mid- to long-term cohort study adds to the literature lacking support for thermal capsulorrhaphy in general, particularly posterior instability.

Keywords

shoulder instability arthroscopic shoulder stabilization thermal capsulorrhaphy outcomes 

Supplementary material

11420_2010_9187_MOESM1_ESM.doc (54 kb)
ESM 1(DOC 54 kb)

References

  1. 1.
    Altchek DW, Warren RF, Skyhar MJ, Ortiz G. T-plasty modification of the Bankart procedure for multidirectional instability of the anterior and inferior types. J Bone Joint Surg Am. 1991;73(1):105–12.PubMedGoogle Scholar
  2. 2.
    Anderson K, Warren RF, Altchek DW, Craig EV, O’Brien SJ. Risk factors for early failure after thermal capsulorrhaphy. Am J Sports Med. 2002;30(1):103–07.PubMedGoogle Scholar
  3. 3.
    Andrews JR, Dugas JR. Diagnosis and treatment of shoulder injuries in the throwing athlete: the role of thermal-assisted capsular shrinkage. Instr Course Lect. 2001;50:17–1.PubMedGoogle Scholar
  4. 4.
    Arnoczky SP, Aksan A. Thermal modification of connective tissues: basic science considerations and clinical implications. J Am Acad Orthop Surg. 2000;8(5):305–13.PubMedGoogle Scholar
  5. 5.
    Bailie DS, Ellenbecker TS. Severe chondrolysis after shoulder arthroscopy: a case series. J Shoulder Elbow Surg. 2009;18(5):742–47.PubMedCrossRefGoogle Scholar
  6. 6.
    Ball CM, Steger T, Galatz LM, Yamaguchi K. The posterior branch of the axillary nerve: an anatomic study. J Bone Joint Surg Am. 2003;85(8):1497–501.PubMedGoogle Scholar
  7. 7.
    Barber FA, Uribe JW, Weber SC. Current applications for arthroscopic thermal surgery. Arthroscopy. 2002;18(2 Suppl 1):40–0.PubMedCrossRefGoogle Scholar
  8. 8.
    Campbell MJ, Machin D. Medical Statistics. A Commonsense Approach. New York: John Wiley & Sons; 1990Google Scholar
  9. 9.
    Chang JH, Hsu AT, Lee SJ, Chang GL. Immediate effect of thermal capsulorrhaphy on glenohumeral joint mobility. Clin Biomech (Bristol, Avon). 2004;19(6):572–78CrossRefGoogle Scholar
  10. 10.
    Ciccone WJ, 2nd, Weinstein DM, Elias JJ. Glenohumeral chondrolysis following thermal capsulorrhaphy. Orthopedics. 2007;30(2):158–60.PubMedGoogle Scholar
  11. 11.
    Coobs BR, LaPrade RF. Severe chondrolysis of the glenohumeral joint after shoulder thermal capsulorrhaphy. Am J Orthop. 2009;38(2):E34–7.PubMedGoogle Scholar
  12. 12.
    Creighton RA, Romeo AA, Brown FM, Jr., Hayden JK, Verma NN. Revision arthroscopic shoulder instability repair. Arthroscopy. 2007;23(7):703–09.PubMedCrossRefGoogle Scholar
  13. 13.
    D’Alessandro DF, Bradley JP, Fleischli JE, Connor PM. Prospective evaluation of thermal capsulorrhaphy for shoulder instability: indications and results, two- to five-year follow-up. Am J Sports Med. 2004;32(1):21–3.PubMedCrossRefGoogle Scholar
  14. 14.
    Dugas JR, Andrews JR. Thermal capsular shrinkage in the throwing athlete. Clin Sports Med. 2002;21(4):771–76.PubMedCrossRefGoogle Scholar
  15. 15.
    Esmail AN, Getz CL, Schwartz DM, Wierzbowski L, Ramsey ML, Williams GR, Jr. Axillary nerve monitoring during arthroscopic shoulder stabilization. Arthroscopy. 2005;21(6):665–71.PubMedCrossRefGoogle Scholar
  16. 16.
    Fanton GS, Khan AM. Monopolar radiofrequency energy for arthroscopic treatment of shoulder instability in the athlete. Orthop Clin North Am. 2001;32(3):511–23.PubMedCrossRefGoogle Scholar
  17. 17.
    Fanton GS, Wall MS. Thermally-assisted arthroscopic stabilization of the shoulder joint. In: Warren RF, Craig EV, Altchek DW, eds. The Unstable Shoulder. Philadelphia, PA: Lippincott-Raven; 1999:329–43.Google Scholar
  18. 18.
    Fitzgerald BT, Watson BT, Lapoint JM. The use of thermal capsulorrhaphy in the treatment of multidirectional instability. J Shoulder Elbow Surg. 2002;11(2):108–13.PubMedCrossRefGoogle Scholar
  19. 19.
    Gartsman GM, Roddey TS, Hammerman SM. Arthroscopic treatment of anterior-inferior glenohumeral instability. Two to five-year follow-up. J Bone Joint Surg Am. 2000;82(7):991–003.PubMedGoogle Scholar
  20. 20.
    Gartsman GM, Roddey TS, Hammerman SM. Arthroscopic treatment of bidirectional glenohumeral instability: two- to five-year follow-up. J Shoulder Elbow Surg. 2001;10(1):28–6.PubMedCrossRefGoogle Scholar
  21. 21.
    Giffin JR, Annunziata CC, Bradley JP. Thermal capsulorrhaphy for instability of the shoulder: multidirectional and posterior instabilities. Instr Course Lect. 2001;50:23–8.PubMedGoogle Scholar
  22. 22.
    Good CR, Shindle MK, Griffith MH, Wanich T, Warren RF. Effect of radiofrequency energy on glenohumeral fluid temperature during shoulder arthroscopy. J Bone Joint Surg Am. 2009;91(2):429–34.PubMedCrossRefGoogle Scholar
  23. 23.
    Good CR, Shindle MK, Kelly BT, Wanich T, Warren RF. Glenohumeral chondrolysis after shoulder arthroscopy with thermal capsulorrhaphy. Arthroscopy. 2007;23(7):797. e1–e5Google Scholar
  24. 24.
    Greis PE, Burks RT, Schickendantz MS, Sandmeier R. Axillary nerve injury after thermal capsular shrinkage of the shoulder. J Shoulder Elbow Surg. 2001;10(3):231–35.PubMedCrossRefGoogle Scholar
  25. 25.
    Gryler EC, Greis PE, Burks RT, West J. Axillary nerve temperatures during radiofrequency capsulorrhaphy of the shoulder. Arthroscopy. 2001;17(6):567–72.PubMedCrossRefGoogle Scholar
  26. 26.
    Hawkins RJ, Karas SG. Arthroscopic stabilization plus thermal capsulorrhaphy for anterior instability with and without Bankart lesions: the role of rehabilitation and immobilization. Instr Course Lect. 2001;50:13–5.PubMedGoogle Scholar
  27. 27.
    Hawkins RJ, Krishnan SG, Karas SG, Noonan TJ, Horan MP. Electrothermal arthroscopic shoulder capsulorrhaphy: a minimum 2-year follow-up. Am J Sports Med. 2007;35(9):1484–488.PubMedCrossRefGoogle Scholar
  28. 28.
    Hayashi K, Hecht P, Thabit GI, Peters DM, Vanderby R, Jr., Cooley AJ, Fanton GS, Orwin JF, Markel MD. The biologic response to laser thermal modification in an in vivo sheep model. Clinical Orthopaedics & Related Research. 2000(373):265–76PubMedCrossRefGoogle Scholar
  29. 29.
    Hayashi K, Markel MD. Thermal capsulorrhaphy treatment of shoulder instability: basic science. Clin Orthop Relat Res. 2001(390):59–72Google Scholar
  30. 30.
    Hayashi K, Massa KL, Thabit GI, Fanton GS, Dillingham MF, Gilchrist KW, Markel MD. Histologic evaluation of the glenohumeral joint capsule after the laser-assisted capsular shift procedure for glenohumeral instability. Am J Sports Med. 1999;27(2):162–67.PubMedGoogle Scholar
  31. 31.
    Hayashi K, Thabit G, 3rd, Massa KL, Bogdanske JJ, Cooley AJ, Orwin JF, Markel MD. The effect of thermal heating on the length and histologic properties of the glenohumeral joint capsule. Am J Sports Med. 1997;25(1):107–112.PubMedCrossRefGoogle Scholar
  32. 32.
    Hecht P, Hayashi K, Cooley AJ, Lu Y, Fanton GS, Thabit G, 3rd, Markel MD. The thermal effect of monopolar radiofrequency energy on the properties of joint capsule. An in vivo histologic study using a sheep model. Am J Sports Med. 1998;26(6):808–814PubMedGoogle Scholar
  33. 33.
    Hecht P, Hayashi K, Lu Y, Fanton GS, Thabit G, 3rd, Vanderby R, Jr., Markel MD. Monopolar radiofrequency energy effects on joint capsular tissue: potential treatment for joint instability. An in vivo mechanical, morphological, and biochemical study using an ovine model. Am J Sports Med. 1999;27(6):761–771PubMedGoogle Scholar
  34. 34.
    Kaplan EL, Meier P. Nonparametric estimation from incomplete observation. J Am Statist Assn. 1958;53:457–481.CrossRefGoogle Scholar
  35. 35.
    Karas SG, Creighton RA, DeMorat GJ. Glenohumeral volume reduction in arthroscopic shoulder reconstruction: a cadaveric analysis of suture plication and thermal capsulorrhaphy. Arthroscopy. 2004;20(2):179–184.PubMedCrossRefGoogle Scholar
  36. 36.
    Kropf EJ, Tjoumakaris FP, Sekiya JK. Arthroscopic shoulder stabilization: is there ever a need to open? Arthroscopy. 2007;23(7):779–784.PubMedCrossRefGoogle Scholar
  37. 37.
    Kumpers P, Potzl W, Heusner T, Steinbeck J, Szuwart T. Cellularity and apoptosis after radiofrequency-induced shrinkage of collagenous tissue: assessment of postoperative immobilization using an in vivo rabbit model. Acta Orthop. 2005;76(4):487–495.PubMedCrossRefGoogle Scholar
  38. 38.
    L’Insalata JC, Warren RF, Cohen SB, Altchek DW, Peterson MG. A self-administered questionnaire for assessment of symptoms and function of the shoulder. J Bone Joint Surg Am. 1997;79(5):738–748.PubMedCrossRefGoogle Scholar
  39. 39.
    Levine WN, Bigliani LU, Ahmad CS. Thermal capsulorrhaphy. Orthopedics. 2004;27(8):823–826.PubMedGoogle Scholar
  40. 40.
    Levine WN, Clark AM, Jr., D’Alessandro DF, Yamaguchi K. Chondrolysis following arthroscopic thermal capsulorrhaphy to treat shoulder instability. A report of two cases. J Bone Joint Surg Am. 2005;87(3):616–621PubMedCrossRefGoogle Scholar
  41. 41.
    Levine WN, Prickett WD, Prymka M, Yamaguchi K. Treatment of the athlete with multidirectional shoulder instability. Orthop Clin North Am. 2001;32(3):475–484.PubMedCrossRefGoogle Scholar
  42. 42.
    Levitz CL, Dugas J, Andrews JR. The use of arthroscopic thermal capsulorrhaphy to treat internal impingement in baseball players. Arthroscopy. 2001;17(6):573–577.PubMedCrossRefGoogle Scholar
  43. 43.
    Levy O, Wilson M, Williams H, Bruguera JA, Dodenhoff R, Sforza G, Copeland S. Thermal capsular shrinkage for shoulder instability. Mid-term longitudinal outcome study. J Bone Joint Surg Br. 2001;83(5):640–645PubMedCrossRefGoogle Scholar
  44. 44.
    Liao WL, Hedman TP, Vangsness CT, Jr. Thermal profile of radiofrequency energy in the inferior glenohumeral ligament. Arthroscopy. 2004;20(6):603–608.PubMedCrossRefGoogle Scholar
  45. 45.
    Lu Y, Bogdanske J, Lopez M, Cole BJ, Markel MD. Effect of simulated shoulder thermal capsulorrhaphy using radiofrequency energy on glenohumeral fluid temperature. Arthroscopy. 2005;21(5):592–596.PubMedCrossRefGoogle Scholar
  46. 46.
    Lu Y, Hayashi K, Edwards RBI, Fanton GS, Thabit G, 3rd, Markel MD. The effect of monopolar radiofrequency treatment pattern on joint capsular healing. In vitro and in vivo studies using an ovine model. Am J Sports Med. 2000;28(5):711–719PubMedGoogle Scholar
  47. 47.
    Lu Y, Markel MD, Kalscheur V, Ciullo JR, Ciullo JV. Histologic evaluation of thermal capsulorrhaphy of human shoulder joint capsule with monopolar radiofrequency energy during short- to long-term follow-up. Arthroscopy. 2008;24(2):203–209.PubMedCrossRefGoogle Scholar
  48. 48.
    Lubowitz JH, Poehling GG. Glenohumeral thermal capsulorrhaphy is not recommended--shoulder chondrolysis requires additional research. Arthroscopy. 2007;23(7):687.PubMedCrossRefGoogle Scholar
  49. 49.
    Luke TA, Rovner AD, Karas SG, Hawkins RJ, Plancher KD. Volumetric change in the shoulder capsule after open inferior capsular shift versus arthroscopic thermal capsular shrinkage: A cadaveric model. J Shoulder Elbow Surg. 2004;13(2):146–149.PubMedCrossRefGoogle Scholar
  50. 50.
    Massoud SN, Levy O, de los Manteros OE, Musa F, Even T, Sinha J, Copeland SA. Histologic evaluation of the glenohumeral joint capsule after radiofrequency capsular shrinkage for atraumatic instability. J Shoulder Elbow Surg. 2007;16(2):163–168PubMedCrossRefGoogle Scholar
  51. 51.
    McCarty EC, Warren RF, Deng XH, Craig EV, Potter H. Temperature along the axillary nerve during radiofrequency-induced thermal capsular shrinkage. Am J Sports Med. 2004;32(4):909–914.PubMedCrossRefGoogle Scholar
  52. 52.
    McFarland EG, Kim TK, Banchasuek P, McCarthy EF. Histologic evaluation of the shoulder capsule in normal shoulders, unstable shoulders, and after failed thermal capsulorrhaphy. Am J Sports Med. 2002;30(5):636–642.PubMedGoogle Scholar
  53. 53.
    McKeon B, Baltz MS, Curtis A, Scheller A. Fluid temperatures during radiofrequency use in shoulder arthroscopy: a cadaveric study. J Shoulder Elbow Surg. 2007;16(1):107–111.PubMedCrossRefGoogle Scholar
  54. 54.
    McNickle AG, L’Heureux DR, Provencher MT, Romeo AA, Cole BJ. Postsurgical glenohumeral arthritis in young adults. Am J Sports Med. 2009;37(9):1784–1791.PubMedCrossRefGoogle Scholar
  55. 55.
    Medvecky MJ, Ong BC, Rokito AS, Sherman OH. Thermal capsular shrinkage: Basic science and clinical applications. Arthroscopy. 2001;17(6):624–635.PubMedCrossRefGoogle Scholar
  56. 56.
    Miniaci A, Codsi MJ. Thermal capsulorrhaphy for the treatment of shoulder instability. Am J Sports Med. 2006;34(8):1356–1363.PubMedCrossRefGoogle Scholar
  57. 57.
    Miniaci A, McBirnie J. Thermal capsular shrinkage for treatment of multidirectional instability of the shoulder. J Bone Joint Surg Am. 2003;85-A(12):2283–2287PubMedGoogle Scholar
  58. 58.
    Mishra DK, Fanton GS. Two-year outcome of arthroscopic bankart repair and electrothermal-assisted capsulorrhaphy for recurrent traumatic anterior shoulder instability. Arthroscopy. 2001;17(8):844–849.PubMedCrossRefGoogle Scholar
  59. 59.
    Mohtadi NG, Hollinshead RM, Ceponis PJ, Chan DS, Fick GH. A multi-centre randomized controlled trial comparing electrothermal arthroscopic capsulorrhaphy versus open inferior capsular shift for patients with shoulder instability: protocol implementation and interim performance: lessons learned from conducting a multi-centre RCT [ISRCTN68224911; NCT00251160]. Trials. 2006;7:4.PubMedCrossRefGoogle Scholar
  60. 60.
    Naseef GS, 3rd, Foster TE, Trauner K, Solhpour S, Anderson RR, Zarins B. The thermal properties of bovine joint capsule. The basic science of laser- and radiofrequency-induced capsular shrinkage. Am J Sports Med. 1997;25(5):670–674PubMedCrossRefGoogle Scholar
  61. 61.
    O’Neill DB. Arthroscopic Bankart repair of anterior detachments of the glenoid labrum. A prospective study. J Bone Joint Surg Am. 1999;81(10):1357–1366.PubMedGoogle Scholar
  62. 62.
    Osmond C, Hecht P, Hayashi K, Hansen S, Fanton GS, Thabit G, 3rd, Markel MD. Comparative effects of laser and radiofrequency energy on joint capsule. Clin Orthop Relat Res. 2000(375):286–294Google Scholar
  63. 63.
    Petty DH, Jazrawi LM, Estrada LS, Andrews JR. Glenohumeral chondrolysis after shoulder arthroscopy: case reports and review of the literature. Am J Sports Med. 2004;32(2):509–515.PubMedCrossRefGoogle Scholar
  64. 64.
    Rath E, Richmond JC. Capsular disruption as a complication of thermal alteration of the glenohumeral capsule. Arthroscopy. 2001;17(3):E10.PubMedCrossRefGoogle Scholar
  65. 65.
    Reinold MM, Wilk KE, Hooks TR, Dugas JR, Andrews JR. Thermal-assisted capsular shrinkage of the glenohumeral joint in overhead athletes: a 15- to 47-month follow-up. J Orthop Sports Phys Ther. 2003;33(8):455–467.PubMedGoogle Scholar
  66. 66.
    Savoie FHI, Field LD. Thermal versus suture treatment of symptomatic capsular laxity. Clin Sports Med. 2000;19(1):63–75.PubMedCrossRefGoogle Scholar
  67. 67.
    Selecky MT, Tibone JE, Yang BY, McMahon PJ, Lee TQ. Glenohumeral joint translation after arthroscopic thermal capsuloplasty of the rotator interval. J Shoulder Elbow Surg. 2003;12(2):139–143.PubMedCrossRefGoogle Scholar
  68. 68.
    Solomon DJ, Navaie M, Stedje-Larsen ET, Smith JC, Provencher MT. Glenohumeral chondrolysis after arthroscopy: a systematic review of potential contributors and causal pathways. Arthroscopy. 2009;25(11):1329–1342.PubMedCrossRefGoogle Scholar
  69. 69.
    Sperling JW, Anderson K, McCarty EC, Warren RF. Complications of thermal capsulorrhaphy. Instr Course Lect. 2001;50:37–41.PubMedGoogle Scholar
  70. 70.
    Tibone JE, Lee TQ, Black AD, Sandusky MD, McMahon PJ. Glenohumeral translation after arthroscopic thermal capsuloplasty with a radiofrequency probe. J Shoulder Elbow Surg. 2000;9(6):514–518.PubMedCrossRefGoogle Scholar
  71. 71.
    Tibone JE, McMahon PJ, Shrader TA, Sandusky MD, Lee TQ. Glenohumeral joint translation after arthroscopic, nonablative, thermal capsuloplasty with a laser. Am J Sports Med. 1998;26(4):495–498.PubMedGoogle Scholar
  72. 72.
    Victoroff BN, Deutsch A, Protomastro P, Barber JE, Davy DT. The effect of radiofrequency thermal capsulorrhaphy on glenohumeral translation, rotation, and volume. J Shoulder Elbow Surg. 2004;13(2):138–145.PubMedCrossRefGoogle Scholar
  73. 73.
    Wall MS, Deng XH, Torzilli PA, Doty SB, O’Brien SJ, Warren RF. Thermal modification of collagen. J Shoulder Elbow Surg. 1999;8(4):339–344.PubMedCrossRefGoogle Scholar
  74. 74.
    Wallace AL, Hollinshead RM, Frank CB. The scientific basis of thermal capsular shrinkage. J Shoulder Elbow Surg. 2000;9(4):354–360.PubMedCrossRefGoogle Scholar
  75. 75.
    Wallace AL, Hollinshead RM, Frank CB. Electrothermal shrinkage reduces laxity but alters creep behavior in a lapine ligament model. J Shoulder Elbow Surg. 2001;10(1):1–6.PubMedCrossRefGoogle Scholar
  76. 76.
    Wallace AL, Hollinshead RM, Frank CB. Creep behavior of a rabbit model of ligament laxity after electrothermal shrinkage in vivo. Am J Sports Med. 2002;30(1):98–102.PubMedGoogle Scholar
  77. 77.
    Wilk KE, Reinold MM, Dugas JR, Andrews JR. Rehabilitation following thermal-assisted capsular shrinkage of the glenohumeral joint: current concepts. J Orthop Sports Phys Ther. 2002;32(6):268–292.PubMedGoogle Scholar
  78. 78.
    Wolf RS, Lemak LJ. Thermal capsulorrhaphy in the treatment of multidirectional instability of the shoulder. J South Orthop Assoc. 2002;11(2):102–109.PubMedGoogle Scholar
  79. 79.
    Wong KL, Williams GR. Complications of thermal capsulorrhaphy of the shoulder. J Bone Joint Surg Am. 2001;83(Suppl 2 Pt 2):151–155.PubMedGoogle Scholar

Copyright information

© Hospital for Special Surgery 2010

Authors and Affiliations

  • Alison P. Toth
    • 1
  • Russell F. Warren
    • 2
  • Frank A. Petrigliano
    • 3
  • David A. Doward
    • 4
  • Frank A. Cordasco
    • 2
  • David W. Altchek
    • 2
  • Stephen J. O’Brien
    • 2
  1. 1.Duke Sports Medicine CenterDurhamUSA
  2. 2.Sports Medicine and Shoulder ServiceHospital for Special SurgeryNew YorkUSA
  3. 3.David Geffen School of MedicineUniversity of California at Los AngelesLos AngelesUSA
  4. 4.Jacksonville Orthopaedic InstituteJacksonvilleUSA

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